Healthcare Provider Details

I. General information

NPI: 1285378935
Provider Name (Legal Business Name): RANDOLPH SPEECH THERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2022
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 TREE FROG WAY
ST AUGUSTINE FL
32095-7523
US

IV. Provider business mailing address

131 TREE FROG WAY
ST AUGUSTINE FL
32095-7523
US

V. Phone/Fax

Practice location:
  • Phone: 208-608-0906
  • Fax:
Mailing address:
  • Phone: 208-608-0906
  • Fax: 904-417-7021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: HEATHER RANDOLPH
Title or Position: OWNER/CLINICIAN
Credential: M.S., CCC-SLP
Phone: 208-608-0906